During the recent Association of Municipalities of Ontario (AMO) conference in Ottawa, Ontario’s Big City Mayors held a press conference describing what municipalities across the province are confronting: encampments that never seem to disappear, overdoses, growing pressure on emergency services and people cycling repeatedly through shelters, hospitals, police and the justice system.

That same week, the Globe and Mail reported on the continuing litigation arising from Canada’s shameful history of institutions such as Huronia and the Rideau Regional Centre. The timing was striking.

Not that long ago, governments dealt with people with significant disabilities in ways we now recognize as profoundly inhumane. That history rightly makes policy-makers wary of anything that sounds like a return to institutionalization. Nobody wants the Nurse Ratched solution. However, fear of repeating the mistakes of the past cannot become an excuse for accepting an equally unacceptable status quo.

In cities across Canada, physicians are sounding the alarm about another crisis hiding within the overlapping crises of homelessness, addiction, mental illness and public safety: severe cognitive impairment. In Ottawa, we see it every day alongside police officers, paramedics, emergency room staff, shelter and outreach workers, as well as bylaw officers and people working in our courts, as well as residents, tourists and businesses.

A person may be on Rideau Street one morning, in an emergency department that evening, back at a shelter the next day, and interacting with police a few days later. Eventually, they are back on the street, and the cycle begins again.

Research suggests severe cognitive impairment is remarkably common among people experiencing chronic homelessness. It can result from compounding events, even from birth.  It can start as Fetal Alcohol Syndrome Disorder, followed by childhood trauma and adverse childhood experiences, leading to mental health concerns which lead to cognitive decline.  Those with FASD, are highly prone to behavioral concerns, which can lead to traumatic brain injuries. They are also at high risk of substance use leading high risk of hypoexemic brain injury from repeated overdoses or mini strokes from methamphetamine use.  Each factor is a hit towards their overall cognition.  These injuries and conditions can accumulate over a lifetime.

FASD deserves particular attention because its symptoms expose a fundamental problem with how our systems operate. FASD can impair planning, attention, working memory, financial management, impulse regulation, and the ability to understand consequences. These are not minor inconveniences. They are precisely the skills we demand from someone trying to navigate our health, housing, shelter and justice systems. Research cited in the policy proposal indicates that up to 60 per cent of people with FASD interact with the criminal justice system.

Now add a traumatic brain injury. Add several overdoses. Add years of living outside. Add untreated mental illness or substance use, and then consider what we ask that person to do:

Remember an appointment next Tuesday. Keep track of identification. Fill out a housing application. Show up at the right office at the right time. Remember what the caseworker said. Manage medication. Follow shelter rules. Control an impulse during a confrontation. Understand conditions imposed by a court. Keep a phone charged so somebody can reach you. Manage money. Meet the conditions of a lease.

Then imagine asking someone to do all of that when the part of their brain responsible for planning, memory, impulse control, and understanding consequences is seriously impaired, and when they cannot, we often treat the failure as a choice or autonomy, and this is where we see a profound equity problem in our health and social systems.

That same week as AMO, the Globe and Mail profiled an innovative private community for people living with dementia. Residents live in small cottages, spend time outdoors, garden, interact with animals and receive the supervision, care and companionship appropriate to their level of cognitive decline. It is not cheap. Monthly fees start at $11,740 for assisted living and rise to $15,740 for extended and complex care but nobody looks at a person with advanced dementia receiving that level of support and asks why they cannot simply be more independent.

We understand that their cognitive impairment has changed what they are capable of doing, and we build care around those limitations. But there is something fundamentally inequitable about a system in which one person’s cognitive impairment leads us to surround them with care, while another person’s cognitive impairment leads us to repeatedly return them to the street.

We think there is a better way.

Intensive Housing

This is why the three or four of us are supporting the creation of a new form of housing for consideration in the 2027 federal budget: Intensive Housing.

The Canadian Alliance to End Homelessness is calling on the federal government to invest $2 billion in capital funding to build a minimum of 6,000 Intensive Housing units across Canada, while working with provinces and territories to establish a sustainable operating funding framework. The underlying policy work proposes a $2-billion federal capital fund capable of creating approximately 6,250 units, paired with long-term provincial and territorial operating support.

The cost is significant. But so is the cost of continuing to leave people in a cycle of repeat emergency visits, lengthy hospital stays and repeated interactions with the justice system, none of it improving their situation over the long term. And to be clear, this is a relatively small group of people.

Housing First remains the right approach for the vast majority of people experiencing homelessness. Intensive Housing is for people with severe cognitive impairment for whom an apartment, a caseworker and occasional visits from a support team are simply not enough. Within the shelter system, it is often referred to as housing the unhousable.  Think of it as the missing highest level of care in our housing system.

Intensive Housing would provide 24-hour residential support, with nurses and health-care aides, medication management, addiction and mental health care, structured routines, occupational and physical therapy, and cognitive rehabilitation where appropriate. For people who lack the capacity to make certain decisions independently, it would also provide proper clinical assessments and access to legal guardianship and decision-making supports. We would also suggest that the recent 150 million in settlement funds from Perdue Pharma could kickstart the construction of these long-term care settings, much like they have in other jurisdictions.

Intensive Care Explained

Any proposal involving 24-hour residential care for vulnerable people should make us cautious.

Canada has a shameful history of institutionalizing people because they were disabled, mentally ill, Indigenous, poor, or simply did not conform to what society expected of them. We should be deeply suspicious of any system that gives the state power over vulnerable people without strong protections. That history is an argument for doing this carefully. It is not an argument for doing nothing.

Intensive Housing is based on modern long-term care, not psychiatric institutionalization. Placement would be based on assessed clinical and functional need, not whether someone is disruptive, uses drugs, sleeps somewhere we do not like, or has had contact with police. The objective is stability, rehabilitation where possible, safety and dignity, not punishment or containment.

Residents must retain rights and access to advocacy, legal counsel and independent oversight. Twenty-four-hour support would have to be determined to be the least restrictive setting capable of meeting the person’s needs. There are legitimate questions about consent, capacity and individual rights. Those questions cannot be brushed aside. Independent advocacy, legal aid, capacity safeguards, regular reviews and transparent oversight must be built into the model from the beginning.

Ottawa is already paying

This conversation is particularly urgent in downtown Ottawa. The concentration of shelters, homelessness services and people with the most complex needs in and around downtown means residents of Lowertown, Sandy Hill and Vanier see the consequences of the current system every day but so do the people trapped inside it. This is not only failing people. It is expensive.

We are already paying for repeat emergency department visits, lengthy hospital stays, ambulance trips, police responses, shelters, court appearances, and incarceration. Then, after spending all that public money, we frequently return the same profoundly impaired person to the same circumstances and wait for the cycle to begin again.

The $2-billion price tag for Intensive Housing is significant. But the alternative is not free.

We are already spending enormous amounts of public money caring for these individuals. We are simply doing it in the most fragmented, reactive, and expensive way possible, often with little long-term improvement in their lives. A $2-billion investment in at least 6,000 Intensive Housing units is an attempt to replace that revolving door with actual care.

Canada still needs more affordable housing. We need Housing First. We need supportive housing. We need mental health care, addiction treatment, harm reduction and prevention. But we also need the courage to acknowledge something uncomfortable: some people have become so cognitively impaired that independent living is no longer a realistic goal.

Recognizing that is not giving up on them. It is recognizing their disability and providing a level of care that reflects it. For the people we see cycling through Rideau-Vanier and downtown Ottawa every day, perhaps we need to stop asking why they keep failing our systems and start asking why we keep giving them systems they are cognitively incapable of navigating.

That is not independence or autonomy. That is abandonment.

Dr. Monty Ghosh is an addiction medicine physician, and Stéphanie Plante, is Ottawa City Councillor for Rideau-Vanier and Deputy Mayor of the City of Ottawa. Tim Richter is the president and CEO and Maggie Rodrigues is the government relations lead for the Canadian Alliance to End Homelessness .

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